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Endocardite Infectieuse : Rôle de l’Echocardiographie Jean-Luc MONIN, CHU Henri Mondor, Créteil Remerciements: Pr. Gilbert HABIB, CHU La Timone, Marseille.

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Presentation on theme: "Endocardite Infectieuse : Rôle de l’Echocardiographie Jean-Luc MONIN, CHU Henri Mondor, Créteil Remerciements: Pr. Gilbert HABIB, CHU La Timone, Marseille."— Presentation transcript:

1 Endocardite Infectieuse : Rôle de l’Echocardiographie Jean-Luc MONIN, CHU Henri Mondor, Créteil Remerciements: Pr. Gilbert HABIB, CHU La Timone, Marseille 21 ème Congrès du Collège National des Cardiologues Français Paris, 8-10 octobre 2009

2 Henri Mondor Role of Echocardiography in Infective Endocarditis 1. Diagnosis 2. Management 2

3 Henri Mondor Role of Echocardiography in Infective Endocarditis 1. Diagnosis 2. Management 3

4 Henri Mondor Modified Duke criteria for the diagnosis of Infective Endocarditis Li et al. Clin Infect Dis. 2000; 30: MAJOR CRITERIA: MAJOR CRITERIA: - Blood cultures positive for IE - Echocardiography positive for IE: vegetation, abscess, new valvular regurgitation/ dehiscence of prosthetic valve MINOR CRITERIA: MINOR CRITERIA: - Predisposing heart condition, IV drug abuse - Fever (> 38°C) - Vascular phenomena: arterial emboli, mycotic aneurysms, intracranial hemorrhage, … - Immunologic phenomena: Osler’s nodes, Roth’s spots, … - Bacteriological evidence: Positive blood culture but does not meet major criteria 4

5 Henri Mondor Clinical Suspicion of IE Trans-thoracic Echocardiography Prosthetic Valve Prosthetic Valve Intracardiac Intracardiacdevice Positive TTE Poor quality TTE TTE Negative Clinical suspicion of IE HighLow Stop If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days Transesophageal Echocardiography * Habib et al. ESC Guidelines. Eur Heart J Aug 27 5

6 Henri Mondor 1. Diagnosis of vegetation 2. Diagnosis of abscess 3. IE affecting intra-cardiac devices Diagnosis of Infective Endocarditis by Echo: Difficulties are frequent… 6

7 Henri Mondor 1. Diagnosis of vegetation 2. Diagnosis of abscess 3. IE affecting intra-cardiac devices Diagnosis of Infective Endocarditis by Echo: Difficulties are frequent… 7

8 Henri Mondor Sensitivity (%) Specificity (%) Accuracy (%) Vegetations TTE (n=281) TEE (n=269) 79% 83% * 98%99%97%99% Diagnostic value for detecting vegetations: TTE versus TEE Monin et al. J Am Coll Cardiol. 2005; 46: In 80 cases of endocarditis, sensitivity for the detection of vegetation was 58% for TTE versus 90% for TEE (p= 0.001). * P= NS : TTE versus TEE Mugge et al. J Am Coll Cardiol. 1989; 14:

9  Apical 4-chamber view Henri Mondor

10  Apical 4-chamber (Lower plane) Henri Mondor

11  Commissural leak (C2) Color Flow Doppler Henri Mondor

12 Clinical Suspicion of IE Trans-thoracic Echocardiography Prosthetic Valve Prosthetic Valve Intracardiac Intracardiacdevice Positive TTE Poor quality TTE TTE Negative Clinical suspicion of IE HighLow Stop If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days Transesophageal Echocardiography * Habib et al. ESC Guidelines. Eur Heart J Aug 27 12

13  TEE : Inter-commissural plane Henri Mondor

14  Inter-commissural plane + CFD Henri Mondor

15 1. Very small (< 2 mm) vegetation 2. Non vegetant endocarditis 3. Prosthetic and pacemaker endocarditis 4. Mitral valve prolapse with thickened valves 5. Vegetation not yet present or already embolized Echocardiography (even Transesophageal) is not 100% sensitive A negative TEE does not rule out endocarditis If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days Habib et al. ESC Guidelines. Eur Heart J Aug 27 15

16 Henri Mondor 1. Diagnosis of vegetation 2. Diagnosis of abscess 3. IE affecting intra-cardiac devices Diagnosis of Infective Endocarditis by Echo: Difficulties are frequent… 16

17 Henri Mondor Abscess of the aortic root - Better assessed by TEE - Multiple views to assess abscess extension - Difficult diagnosis at the early stage of the disease - Need for frequent TEE controls if non operated Courtesy: Pr. C. Tribouilloy 17

18 Henri Mondor Abscess of the aortic root: Better assessed by TEE Courtesy: Pr. C. Tribouilloy 18

19 Henri Mondor Abscess of the aortic root: Better assessed by TEE Courtesy: Pr. C. Tribouilloy 19

20 Henri Mondor 1. Diagnosis of vegetation 2. Diagnosis of abscess 3. IE affecting intra-cardiac devices Diagnosis of Infective Endocarditis by Echo: Difficulties are frequent… 20

21 Henri Mondor Prosthetic valve endocarditis - Better assessed by TEE - Especially in the mitral position - Reverberations/ artifacts due to the prosthesis - Need for frequent TEE controls if non operated Postoperative D-45 21

22 Henri Mondor Prosthetic valve endocarditis: The role of Transesophageal Echo Postoperative D-45 22

23 Henri Mondor Adapted antibiotics (D+10) Prosthetic valve endocarditis: Repeat TEE if non operated 23

24 Henri Mondor Prosthetic valve endocarditis Adapted antibiotics (D+10) 24

25 Henri Mondor Role of Echocardiography in Infective Endocarditis 1. Diagnosis 2. Management 25

26 Henri Mondor Timing of Surgery in Infective Endocarditis: The 2009 ESC Guidelines INDICATIONS FOR SURGERY TimingClassLevel A/ CONGESTIVE HEART FAILURE Severe acute AR or MR or valve obstruction causing refractory pulmonary oedema / cardiogenic shock EmergencyIB Aortic or mitral IE with fistula causing refractory pulmonary oedema or cardiogenic shock EmergencyIB Severe acute AR or MR or valve obstruction with persistent CHF or echocardiographic signs of poor hemodynamic tolerance (early mitral closure, pulmonary hypertension) UrgentIB Severe acute AR or MR without CHF or any sign of poor tolerance ElectiveIIaB B/ UNCONTROLLED INFECTION Locally uncontrolled: enlarging vegetation, abscess, fistula, false aneurysm) UrgentIB Persisting fever and positive blood cultures > 7-10 days of antibiotics UrgentIB IE due to fungi or multi resistant organisms Urgent/ Elective IB C/ PREVENTION OF EMBOLISM Large aortic or mitral vegetations (>10 mm) following ≥1 embolic episode despite appropriate antibiotics UrgentIB Large aortic or mitral vegetations (>10 mm) with other predictors of complicated course (CHF, persistent infection, abscess) UrgentIC Very large vegetations without any other risk factors UrgentIIbC

27 Henri Mondor Indications for Surgery Timing * ClassLevel Locally uncontrolled: enlarging vegetation, abscess, fistula, false aneurysm) UrgentIB Persisting fever and positive blood cultures > days of antibiotics UrgentIB IE due to fungi or multi resistant organisms Urgent/ Elective IB Timing of Surgery in Infective Endocarditis: Indications for Uncontrolled Infection ESC Guidelines. Eur Heart J Aug 27 27

28 Henri Mondor Emergent surgery (the same day): Acute severe AR with pulmonary oedema Early mitral closure 28

29 Henri Mondor Diastolic MR Emergent surgery (the same day): Acute severe AR with pulmonary oedema 29

30 Henri Mondor Acute severe AR with pulmonary oedema : Limitations of the PHT 30

31 Henri Mondor Timing of Surgery in Infective Endocarditis: Indications for Heart Failure ESC Guidelines. Eur Heart J Aug 27 Indications for Surgery Timing * ClassLevel Severe acute Aortic or mitral regurgitation or valve obstruction causing refractory pulmonary oedema or cardiogenic shock Emergency (within 24 Hours) IB Aortic or mitral IE with fistula causing refractory pulmonary oedema or cardiogenic shock EmergencyIB Severe acute AR or MR or valve obstruction with persistent CHF or echocardiographic signs of poor hemodynamic tolerance (early mitral closure, pulmonary hypertension) Urgent (within 2-3 days) IB Severe acute Aortic or mitral regurgitation without CHF or any sign of poor tolerance ElectiveIIaB 31

32 Henri Mondor 9/45 17/66 10/24 30/ patients, definite IE % Embolic events Di Salvo et al. J Am Coll Cardiol. 2001; 37: Risk of systemic embolism according to Vegetation size (TEE) 32

33 Henri Mondor Thuny et al. Circulation. 2005; 112: Risk of systemic embolism under appropriate antibiotics % New Embolic Events 384 patients with definite IE, European multicentre study 384 patients with definite IE, European multicentre study Embolic events: n= 131 (34%), of which 28 (7.3%) under therapy Embolic events: n= 131 (34%), of which 28 (7.3%) under therapy Under therapy: 20 events (71.4%) during the first 15 days Under therapy: 20 events (71.4%) during the first 15 days 33

34 Henri Mondor Fabri et al. Int J Cardiol ; 110 : cases of IE, 133 embolic events (21.1 %) 629 cases of IE, 133 embolic events (21.1 %) Risk of systemic embolism under appropriate antibiotics THE RISK OF EMBOLIC EVENTS: 1.Dramatically decreases after initiation of ATB 2.Remains high during the first 2 weeks of ATB 3.Is related to the size /mobility of the vegetations 4.May be reduced by early surgery ? 34

35 Henri Mondor ESC Guidelines. Eur Heart J Aug 27 Timing of Surgery in Infective Endocarditis : Prevention of embolism Indications for Surgery Timing * ClassLevel Large aortic or mitral vegetations (>10 mm) following ≥1 embolic episode despite appropriate antibiotics Urgent (within 2-3 days) IB Large aortic or mitral vegetations (>10 mm) with other predictors of complicated course : (CHF, persistent infection, abscess) UrgentIC Very large vegetations without any other risk factors UrgentIIbC 35

36 Henri Mondor Isolated large vegetation > 15 mm: Urgent surgery is required (Class IIb) 36

37 Henri Mondor 1. Echocardiography plays a key role in the diagnosis and management of patients with infective endocarditis 2. Transesophageal echo is mandatory in the majority of patients 3. A negative TEE does not rule out endocarditis: repeat TEE after 7-10 days if suspicion if IE remains 4. Early indications for surgery (CHF, uncontrolled infection or prevention of embolism) are mainly based on echocardiography (TEE ++) Take-Home messages 37

38 Henri Mondor 38


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